LEWIS'S MEDICAL-SURGICAL NURSING
ASSESSMENT AND MANAGEMENT OF
CLINICAL PROBLEMS, SINGLE VOLUME
12TH EDITION
• AUTHOR(S)MARIANN M. HARDING;
JEFFREY KWONG; DEBRA HAGLER;
COURTNEY REINISCH
TEST BANK
1
Reference: Ch. 1 — Professional Nursing — Scope of Nursing
Practice
Stem: A newly licensed nurse is assigned a hospitalized patient
with complex wound care and multiple comorbidities. The
nurse’s state board and hospital policy require adherence to
scope of practice. Which action best demonstrates practicing
within the nursing scope while ensuring patient safety?
A. Independently modify the physician’s wound dressing order
,to use a different dressing that healed faster in past patients.
B. Clarify the physician’s order with the wound-care team and
request a consult before changing the plan.
C. Ask the nursing assistant to perform the dressing change
because the assistant worked with similar wounds before.
D. Delay the dressing change until the next shift to avoid making
changes without approval.
Correct answer: B
Rationale — Correct: Choosing to clarify and request a wound-
care consult follows Lewis’s emphasis on working within scope,
using interprofessional resources, and ensuring safe, evidence-
based care. This follows the CJM: Recognize (uncertainty),
Analyze (risks/benefits), Plan (consult), Intervene (collaborate),
Evaluate (outcome).
Rationale — Incorrect:
A: Unsafe — altering orders independently exceeds nursing
scope and risks harm.
C: Delegating to an assistant for a complex procedure is
inappropriate and unsafe.
D: Delaying care may cause harm; appropriate action is to
clarify immediately.
Teaching point: Clarify orders and use interprofessional consults
when care exceeds scope.
Citation: Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C.
(2023). Lewis’s Medical–Surgical Nursing (12th Ed.). Ch. 1.
,2
Reference: Ch. 1 — Professional Nursing — Standards of
Professional Nursing Practice
Stem: A nurse documents that a postoperative patient’s
respiratory rate is 10 breaths/min and O₂ saturation is 88% on
room air. According to professional standards, what is the most
appropriate immediate action?
A. Increase room air stimulation and recheck vitals in 30
minutes.
B. Apply oxygen per protocol and notify the provider
immediately.
C. Document and continue routine monitoring every hour.
D. Encourage deep-breathing exercises and ambulation.
Correct answer: B
Rationale — Correct: Low RR and SpO₂ are unstable findings
requiring immediate oxygen therapy and provider notification
per Lewis’s safety/standard guidelines; CJM: Recognize serious
change → Analyze severity → Plan oxygen and notify →
Intervene promptly → Evaluate response.
Rationale — Incorrect:
A: Waiting 30 minutes risks deterioration.
C: Routine monitoring is insufficient for hypoxemia.
D: Deep-breathing alone is inadequate in acute hypoxemia.
Teaching point: Treat SpO₂ <90% promptly with oxygen and
notify the provider.
Citation: Harding et al. (2023). Ch. 1.
, 3
Reference: Ch. 1 — Professional Nursing — Clinical Judgment
Stem: A patient with chronic heart failure reports sudden
increased dyspnea and orthopnea; breath sounds reveal
bibasilar crackles and 3+ pitting edema. Using the NCSBN
Clinical Judgment Model, what should the nurse do first?
A. Elevate the head of the bed, apply oxygen, and obtain heart
and lung sounds every 15 minutes.
B. Administer the patient’s PRN albuterol inhaler for dyspnea.
C. Encourage the patient to ambulate to improve lung
expansion.
D. Offer oral fluids and reassess in one hour.
Correct answer: A
Rationale — Correct: Recognize (acute decompensated HF),
Analyze (pulmonary edema risk), Plan/Intervene: elevate,
oxygen, frequent assessment — immediate priorities to
improve oxygenation and reduce preload per Lewis. Evaluate
continuously.
Rationale — Incorrect:
B: Albuterol is for bronchospasm, not pulmonary edema.
C: Ambulation may increase oxygen demand and risk.
D: Oral fluids worsen fluid overload in HF.
Teaching point: In acute HF exacerbation, prioritize oxygenation
and reduce preload.
Citation: Harding et al. (2023). Ch. 1.
ASSESSMENT AND MANAGEMENT OF
CLINICAL PROBLEMS, SINGLE VOLUME
12TH EDITION
• AUTHOR(S)MARIANN M. HARDING;
JEFFREY KWONG; DEBRA HAGLER;
COURTNEY REINISCH
TEST BANK
1
Reference: Ch. 1 — Professional Nursing — Scope of Nursing
Practice
Stem: A newly licensed nurse is assigned a hospitalized patient
with complex wound care and multiple comorbidities. The
nurse’s state board and hospital policy require adherence to
scope of practice. Which action best demonstrates practicing
within the nursing scope while ensuring patient safety?
A. Independently modify the physician’s wound dressing order
,to use a different dressing that healed faster in past patients.
B. Clarify the physician’s order with the wound-care team and
request a consult before changing the plan.
C. Ask the nursing assistant to perform the dressing change
because the assistant worked with similar wounds before.
D. Delay the dressing change until the next shift to avoid making
changes without approval.
Correct answer: B
Rationale — Correct: Choosing to clarify and request a wound-
care consult follows Lewis’s emphasis on working within scope,
using interprofessional resources, and ensuring safe, evidence-
based care. This follows the CJM: Recognize (uncertainty),
Analyze (risks/benefits), Plan (consult), Intervene (collaborate),
Evaluate (outcome).
Rationale — Incorrect:
A: Unsafe — altering orders independently exceeds nursing
scope and risks harm.
C: Delegating to an assistant for a complex procedure is
inappropriate and unsafe.
D: Delaying care may cause harm; appropriate action is to
clarify immediately.
Teaching point: Clarify orders and use interprofessional consults
when care exceeds scope.
Citation: Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C.
(2023). Lewis’s Medical–Surgical Nursing (12th Ed.). Ch. 1.
,2
Reference: Ch. 1 — Professional Nursing — Standards of
Professional Nursing Practice
Stem: A nurse documents that a postoperative patient’s
respiratory rate is 10 breaths/min and O₂ saturation is 88% on
room air. According to professional standards, what is the most
appropriate immediate action?
A. Increase room air stimulation and recheck vitals in 30
minutes.
B. Apply oxygen per protocol and notify the provider
immediately.
C. Document and continue routine monitoring every hour.
D. Encourage deep-breathing exercises and ambulation.
Correct answer: B
Rationale — Correct: Low RR and SpO₂ are unstable findings
requiring immediate oxygen therapy and provider notification
per Lewis’s safety/standard guidelines; CJM: Recognize serious
change → Analyze severity → Plan oxygen and notify →
Intervene promptly → Evaluate response.
Rationale — Incorrect:
A: Waiting 30 minutes risks deterioration.
C: Routine monitoring is insufficient for hypoxemia.
D: Deep-breathing alone is inadequate in acute hypoxemia.
Teaching point: Treat SpO₂ <90% promptly with oxygen and
notify the provider.
Citation: Harding et al. (2023). Ch. 1.
, 3
Reference: Ch. 1 — Professional Nursing — Clinical Judgment
Stem: A patient with chronic heart failure reports sudden
increased dyspnea and orthopnea; breath sounds reveal
bibasilar crackles and 3+ pitting edema. Using the NCSBN
Clinical Judgment Model, what should the nurse do first?
A. Elevate the head of the bed, apply oxygen, and obtain heart
and lung sounds every 15 minutes.
B. Administer the patient’s PRN albuterol inhaler for dyspnea.
C. Encourage the patient to ambulate to improve lung
expansion.
D. Offer oral fluids and reassess in one hour.
Correct answer: A
Rationale — Correct: Recognize (acute decompensated HF),
Analyze (pulmonary edema risk), Plan/Intervene: elevate,
oxygen, frequent assessment — immediate priorities to
improve oxygenation and reduce preload per Lewis. Evaluate
continuously.
Rationale — Incorrect:
B: Albuterol is for bronchospasm, not pulmonary edema.
C: Ambulation may increase oxygen demand and risk.
D: Oral fluids worsen fluid overload in HF.
Teaching point: In acute HF exacerbation, prioritize oxygenation
and reduce preload.
Citation: Harding et al. (2023). Ch. 1.
